Quality Payment Program Year 3

Session 44, February 12, 2019

Molly MacHarris, MIPS Program Lead, CMS

Elizabeth S. Holland, Senior Technical Advisor, CMS

Molly MacHarris, MIPS Program Lead, CMS

Elizabeth S. Holland, Senior Technical Advisor, CMS

Have no real or apparent conflicts of interest to report.

Conflict of Interest

This presentation was prepared as a tool to assist providers and is not intended to grant

rights or impose obligations. Although every reasonable effort has been made to assure

the accuracy of the information within these pages, the ultimate responsibility for the

correct submission of claims and response to any remittance advice lies with the

provider of services.

This publication is a general summary that explains certain aspects of the Medicare

Program, but is not a legal document. The official Medicare Program provisions are

contained in the relevant laws, regulations, and rulings. Medicare policy changes

frequently, and links to the source documents have been provided within the document

for your reference.

The Centers for Medicare & Medicaid Services (CMS) employees, agents, and staff

make no representation, warranty, or guarantee that this compilation of Medicare

information is error-free and will bear no responsibility or liability for the results or

consequences of the use of this presentation.

Disclaimer

• Learning Objectives

• Quality Payment Program Overview

• Quality Payment Program Year 1 (2017) Participation Results

• Merit-based Incentive Payment System (MIPS) Year 2 (2018)

Data Submission

• MIPS Overview

• Final Rule for Year 3 (2019) - MIPS:

– Eligibility

– Reporting Options and Data Submission

– Performance Categories

– Additional Bonuses, Performance Threshold, and Payment

Adjustments

• Quality Payment Program – Help & Support

Presentation Overview

1. Highlight Quality Payment Program Year 1 (2017) performance

data

2. Outline Year 2 (2018) MIPS data submission deadlines and

resources

3. Identify key policy changes for the third year (2019) of the

Quality Payment Program

4. Summarize eligibility, reporting, and data submission

requirements for MIPS in 2019

5. Provide an overview of available resources and no-cost technical

assistance

Learning Objectives

Quality Payment Program Overview

The Medicare Access and CHIP Reauthorization Act of 2015

(MACRA) requires CMS by law to implement an incentive program,

referred to as the Quality Payment Program:

Quality Payment Program

Quick Tip: For additional information on the Quality Payment

Program, please visit qpp.cms.gov

Quality Payment Program

Considerations

Improve beneficiary outcomes

Increase adoption of

Advanced APMs

Improve data and

information sharing

Reduce burden on clinicians

Maximize participation

Ensure operational excellence

in program implementation

Deliver IT systems capabilities that

meet the needs of users

MIPS: Quick Overview

• Comprised of four performance categories

• So what? The points from each performance category are added together to give you

a MIPS Final Score

• The MIPS Final Score is compared to the MIPS performance threshold to determine if

you receive a positive, negative, or neutral payment adjustment

MIPS: Terms to Know

As a refresher…

• TIN (Taxpayer Identification Number)

– Used by the Internal Revenue Service to identify an entity, such as a group

medical practice, that is subject to federal taxes

• NPI (National Provider Identifier)

– 10-digit numeric identifier for individual clinicians

• TIN/NPI

– Identifies the individual clinician and the entity/group practice through which

the clinician bills services to CMS

Performance

Period

Also r

eferred to as…

Corresponding

Payment Year

Corresponding

Adjustment

2017 2017 “Transition” Year 2019 + or - 4%

2018 “Year 2” 2020 + or - 5%

2019 “Year 3” 2021 + or - 7%

Quality Payment Program

Year 1 (2017) Participation Results Review

*Clinicians are identified under the Quality Payment Program by their unique Taxpayer Identification Number/National

Provider Identifier Combination (TIN/NPI)

QPP Year 1 (2017) Performance Data

Payment Adjustments

General Participation in

2017:

• 1,057,824 total MIPS

eligible clinicians* received

a MIPS payment

adjustment (positive,

neutral, or negative)

• 1,006,319 total MIPS

eligible clinicians reported

data and received a

neutral payment

adjustment or better

• 99,076 total Qualifying

APM Participants (QPs)

• 52 total number of Partial

QPs

QPP Year 1 (2017) Performance Data

Mean and Median National Final Score

QPP Year 1 (2017) Performance Data

Mean and Median Final Scores by Submitter Type

*An individual is a single TIN/NPI; a group is two or more NPIs (including at least

one MIPS eligible clinician) billing under a single TIN. The “groups” column

includes APM entity groups.

QPP Year 1 (2017) Performance Data

Mean and Median Final Scores for Large, Small, and Rural Practices

Merit-based Incentive Payment System (MIPS)

Year 2 (2018) Data Submission

April 2, 2019 is the 2018 MIPS data submission deadline.

There are two exceptions specific to the Quality performance

category:

• Clinicians who report Quality measures via Medicare Part B

claims submit their performance data throughout the 2018

performance period (January 1 – December 31, 2018)

• Groups, virtual groups, and Accountable Care Organizations

reporting Quality measures through the CMS Web Interface can

submit their data between January 22 and March 22, 2019

2018 MIPS Data Submission: Key Dates

Submitting 2018 through the QPP website:

• Sign into the QPP website using your HARP credentials:

https://qpp.cms.gov/login

• Submit your 2018 data for/attest to the Quality, Promoting

Interoperability, and Improvement Activities performance

categories

2018 MIPS Data Submission: How to

Submit Data

TIP: You can submit and update your data throughout the

submission period. Your data is automatically saved and clinician

records are updated in real-time. This allows you to come back at

a later time without losing any of the data.

Easily submit and score QPP data in real-time via API:

• Supports cross-origin resource sharing, allowing you to interact

securely with the API from a client-side web application

• API responses can be returned in JSON or XML, including errors

Explore and Integrate with the Submissions API using:

• Interactive Documentation

• Developer Preview Environment

Stay Up to Date:

• QPP APIs Google Group

2018 MIPS Data Submission: API

Documentation

Visit the QPP Resource Library to access 2018 data submission

resources: https://qpp.cms.gov/about/resource-library

Resources include:

• 2018 Data Submission FAQs

• 2018 Data Submission User Guide

• 2018 Data Submission Demo Videos

• 2018 CMS Web Interface User Guides, Templates, Data

Dictionary, and more

• 2018 QPP Access User Guide and Demo Videos about the new

HARP System

2018 MIPS Data Submission:

Resources

MIPS Overview

MIPS: Quick Overview

Combined legacy programs into a single, improved program.

Physician Quality Reporting System

(PQRS)

Value-Based Payment Modifier (VM)

Medicare EHR Incentive Program (EHR)

for Eligible Professionals

MIPS

MIPS: Quick Overview

• Comprised of four performance categories

• So what? The points from each performance category are added together to give you

a MIPS Final Score

• The MIPS Final Score is compared to the MIPS performance threshold to determine if

you receive a positive, negative, or neutral payment adjustment

MIPS: Timeline

• Deadline for

submitting data is

March 31, 2020

• Clinicians are

encouraged to

submit data early

• CMS provides

performance feedback

after the data is

submitted

• Clinicians will receive

feedback before the

start of the payment

year

• MIPS payment

adjustments are

prospectively applied to

each claim for service

furnished beginning

January 1, 2021

2019

Performance Year

March 31, 2020

Data Submission

Feedback

January 1, 2021

Payment Adjustment

Feedback available adjustment

submitPerformance period

• Performance period

opens January 1, 2019

• Closes December 31,

2019

• Clinicians care for

patients and record

data during the year

Final Rule for Year 3 (2019) – MIPS

Eligibility

MIPS Year 3 (2019) Final

MIPS Eligible Clinician Types

MIPS eligible clinicians include:

• Physicians

• Physician Assistants

• Nurse Practitioners

• Clinical Nurse Specialists

• Certified Registered Nurse Anesthetists

• Groups of such clinicians

Year 2 (2018) Final

MIPS eligible clinicians include:

• Same five clinician types from

Year 2 (2018)

AND:

• Clinical Psychologists

• Physical Therapists

• Occupational Therapists

• Speech-Language Pathologists*

• Audiologists*

• Registered Dieticians or Nutrition

Professionals*

Year 3 (2019) Final

*We modified our proposals to add these additional clinician types for Year 3 as a result of the significant support we received during the

comment period

MIPS Year 3 (2019) Final

Low-Volume Threshold Criteria

What do I need to know?

1. Threshold amounts remain the same as in Year 2 (2018)

2. Added a third element – Number of Services – to the low-volume

threshold determination criteria

– The finalized criteria now includes:

• Dollar amount – $90,000 in covered professional services under

the Physician Fee Schedule (PFS)

• Number of beneficiaries – 200 Medicare Part B beneficiaries

• Number of services* (New) – 200 covered professional services

under the PFS

*When we say “service”, we are equating one professional claim line with positive allowed charges to one covered

professional service

MIPS Year 3 (2019) Final

Low-Volume Threshold Determination

How does CMS determine if I am included in MIPS in Year 3 (2019)?

1. Be a MIPS eligible clinician type (as listed on slide 18)

2. Exceed all three elements of the low-volume threshold criteria:

– Bill more than $90,000 a year in allowed charges for covered

professional services under the Medicare Physician Fee Schedule

(PFS)

AND

– Furnish covered professional services to more than 200 Medicare

Part B beneficiaries

AND

– Provide more than 200 covered professional services under the PFS

(New)

MIPS Year 3 (2019) Final

Low-Volume Threshold Determination

What else do I need to know?

Clinicians who:

x DO NOT bill more than $90,000 a year in allowed charges for covered professional

services under the Medicare Physician Fee Schedule (PFS)

x DO NOT furnish covered professional services to more than 200 Medicare beneficiaries

x DO NOT provide more than 200 covered professional services under the PFS (New)

Are excluded from MIPS in Year 3 (2019) and do not need to participate

Remember: To be required to participate, clinicians must:

BILLING

>$90,000

AND

BENEFICIARIES

>200

SERVICES

>200

AND

MIPS Year 3 (2019) Final

Low-Volume Threshold Determination

What happens if I am excluded, but want to participate in MIPS?

You have two options:

1. Voluntarily participate

– You’ll submit data to CMS and receive performance feedback

– You will not receive a MIPS payment adjustment

2. Opt-in (Newly added for Year 3)

– Opt-in is available for MIPS eligible clinicians who are excluded from

MIPS based on the low-volume threshold determination

– If you are a MIPS eligible clinician and meet or exceed at least one,

but not all, of the low-volume threshold criteria, you may opt-in to

MIPS

– If you opt-in, you’ll be subject to the MIPS performance

requirements, MIPS payment adjustment, etc.

MIPS Year 3 (2019) Final

Opt-in Policy

MIPS eligible clinicians who meet or exceed at least one, but not all, of the

low-volume threshold criteria may choose to participate in MIPS

Dollars Beneficiaries

Professional Services

(New)

Eligible for Opt-in?

≤ 90K ≤ 200 ≤ 200 No – excluded

≤ 90K ≤ 200 > 200

Yes (may also voluntarily report or not

participate)

> 90K ≤ 200 ≤ 200

Yes (may also voluntarily report or not

participate)

> 90K ≤ 200 >200

Yes (may also voluntarily report or not

participate)

≤ 90K > 200 > 200

Yes (may also voluntarily report or not

participate)

> 90K > 200 > 200 No – required to participate

MIPS Opt-in Scenarios

MIPS Year 3 (2019) Final

Opt-in Policy - Example

• Did not exceed all three elements of the low-volume threshold determination criteria,

therefore exempt from MIPS in Year 3

However…

• This clinician could opt-in to MIPS and participate in Year 3 (2019) since the clinician

met or exceeded at least one (in this case, two) of the low-volume threshold criteria

and is also a MIPS eligible clinician type

Physical Therapist (Individual)

 Billed $100,000 x Saw 100 patients

 Provided 201 covered

professional services

MIPS Year 3 (2019) Final

Opt-in Policy

What else do I need to know?

• Once an election has been made, the decision to opt-in to MIPS would be

irrevocable and could not be changed

• Clinicians or groups who opt-in are subject to all of the MIPS rules, special status,

and MIPS payment adjustment

• Please note that APM Entities interested in opting-in to participate in MIPS under the

APM Scoring Standard would do so at the APM Entity level

User Research Opportunity:

• If you’re interested in participating in user research for MIPS, we want to hear from

you! We encourage you to send your contact information to:

QPPUserResearch@cms.hhs.gov

MIPS Year 3 (2019) Final

MIPS Determination Period

Low Volume Threshold Determination Period:

• First 12-month segment: Sept. 1, 2016 - Aug. 31, 2017

(including 30-day claims run out)

• Second 12-month segment: Sept. 1, 2017 - Aug. 31,

2018 (including a 30-day claims run out)

Special Status

• Use various determination periods to identify MIPS

eligible clinicians with a special status and apply the

designation.

• Special status includes:

– Non-Patient Facing

– Small Practice

– Rural Practice

– Health Professional Shortage Area (HPSA)

– Hospital-based

– Ambulatory Surgical Center-based (ASC-based)

Year 2 (2018) Final

Change to the MIPS Determination Period:

• First 12-month segment: Oct. 1, 2017 - Sept. 30,

2018 (including a 30-day claims run out)

• Second 12-month segment: Oct. 1, 2018 - Sept. 30,

2019 (does not include a 30-day claims run out)

• Goal: Consolidate the multiple timeframes and align

the determination period with the fiscal year

• Goal: Streamlined period will also identify MIPS

eligible clinicians with the following special status:

Non-Patient Facing

Small Practice

Hospital-based

ASC-based

Note: Rural and HPSA status continue to apply in 2019

Year 3 (2019) Final

Quick Tip: MIPS eligible clinicians with a special status are included in MIPS and qualify for special rules. Having a special status does

not exempt a clinician from MIPS.

Final Rule for Year 3 (2019) – MIPS

Reporting Options and Data Submission

MIPS Year 3 (2019) Final

Reporting Options

What are my reporting options if I am required to participate in MIPS?

Same reporting options as Year 2. Clinicians can report as or part of a/an:

Individual Group

2. As a Group

a) 2 or more clinicians (NPIs),

including at least one MIPS

eligible clinician, who have

reassigned their billing rights

to a single TIN*

b) As an APM Entity

1. As an Individual – under a

National Provider Identifier

(NPI) number and

Taxpayer Identification

Number (TIN) where they

reassign benefits

Virtual Group

3. As a Virtual Group –

made up of solo

practitioners and groups

of 10 or fewer eligible

clinicians who come

together “virtually” (no

matter what specialty or

location) to participate in

MIPS for a performance

period for a year

MIPS Year 3 (2019) Final

Submitting Data - Collection, Submission, and Submitter Types

What do I need to know about submitting my performance data?

• For Year 3 (2019), we have revised existing terms and defined additional terminology

to help clarify the process of submitting data:

– Collection Types

– Submission Types

– Submitter Types

Why did you make this change?

• In Year 2 (2018), we used the term “submission mechanism” all-inclusively when

talking about:

– The method by which data is submitted (e.g., registry, EHR, attestation, etc.)

– Certain types of measures and activities on which data are submitted

– Entities submitting such data (i.e., third party intermediaries submitting on

behalf of a group)

• We found that this caused confusion for clinicians and those submitting on behalf of

clinicians

MIPS Year 3 (2019) Final

Submitting Data - Collection, Submission, and Submitter Types

Definitions for Newly Finalized Terms:

• Collection type- A set of quality measures with comparable specifications and data completeness

criteria including, but not limited to: electronic clinical quality measures (eCQMs); MIPS Clinical

Quality Measures* (MIPS CQMs); Qualified Clinical Data Registry (QCDR) measures; Medicare

Part B claims measures; CMS Web Interface measures; the CAHPS for MIPS survey; and

administrative claims measures.

• Submission type- The mechanism by which a submitter type submits data to CMS, including, but

not limited to: direct, log in and upload, log in and attest, Medicare Part B claims, and the CMS Web

Interface.

– The Medicare Part B claims submission type is for clinicians or groups in small practices

only to continue providing reporting flexibility

• Submitter type- The MIPS eligible clinician, group, virtual group, or third party intermediary acting

on behalf of a MIPS eligible clinician, group, or virtual group, as applicable, that submits data on

measures and activities.

*The term MIPS CQMs would replace what was formerly referred to as “registry measures” since

clinicians that don’t use a registry may submit data on these measures.

MIPS Year 3 (2019) Final

Collection, Submission, and Submitter Types - Example

Data Submission for MIPS Eligible Clinicians Reporting as Individuals

Performance

Category

Submission Type Submitter Type Collection Type

•

Direct

•

Log-in and Upload

• Medicare Part B Claims

(small practices only)

•

Individual

•

Third Party

Intermediary

•

eCQMs

•

MIPS CQMs

•

QCDR Measures

•

Medicare Part B Claims

Measures (small practices

only)

•

No data submission

required

•

Individual

•

Direct

•

Log-in and Upload

•

Log-in and Attest

•

Individual

•

Third Party

Intermediary

•

Direct

•

Log-in and Upload

•

Log-in and Attest

•

Individual

•

Third Party

Intermediary

Quality

Cost

Improvement

Activities

Promoting

Interoperability

MIPS Year 3 (2019) Final

Collection, Submission, and Submitter Types - Example

Data Submission for MIPS Eligible Clinicians Reporting as Groups

Performance

Category

Submission Type Submitter Type Collection Type

•

Direct

•

Log-in and Upload

•

CMS Web Interface (groups of 25

or more eligible clinicians)

•

Medicare Part B Claims (small

practices only)

•

Group

•

Third Party

Intermediary

•

eCQMs

•

MIPS CQMs

•

QCDR Measures

•

CMS Web Interface Measures

•

CMS Approved Survey Vendor Measure

•

Administrative Claims Measures

•

Medicare Part B Claims (small practices only)

•

No data submission required

•

Group

•

Direct

•

Log-in and Upload

•

Log-in and Attest

•

Group

•

Third Party

Intermediary

•

Direct

•

Log-in and Upload

•

Log-in and Attest

•

Group

•

Third Party

Intermediary

Quality

Cost

Improvement

Activities

Promoting

Interoperability

Final Rule for Year 3 (2019) – MIPS

Performance Categories

MIPS Year 3 (2019) Final

Performance Period

Year 2 (2018) Final

Performance

Category

Performance

Period

Quality

12-months

Cost

12-months

Improvement

Activities

90-days

Promoting

Interoperability

90-days

Year 3 (2019) Final - No Change

Performance

Category

Performance

Period

Quality

12-months

Cost

12-months

Improvement

Activities

90-days

Promoting

Interoperability

90-days

MIPS Year 3 (2019) Final

Performance Category Weights

Year 2 (2018) Final

Performance

Category

Performance

Category Weight

Quality

45%

Cost

15%

Improvement

Activities

15%

Promoting

Interoperability

25%

Year 3 (2019) Final

Performance

Category

Performance

Category Weight

Quality

50%

Cost

10%

Improvement

Activities

15%

Promoting

Interoperability

25%

MIPS Year 3 (2019) Final

Quality Performance Category

Basics:

• 45% of Final Score in 2019

• You select 6 individual measures

̶ 1 must be an outcome measure

̶ High-priority measure

• If less than 6 measures apply, then

report on each applicable measure

• You may also select a specialty-

specific set of measures

Meaningful Measures

• Goal: The Meaningful Measures Initiative is aimed at

identifying the highest priority areas for quality

measurement and quality improvement to assess the

core quality of care issues that are most vital to

advancing our work to improve patient outcomes

• For 2019, we are:

̶ Removing 26 quality measures, including

those that are process, duplicative, and/or

topped-out

̶ Adding 8 measures (4 Patient-Reported

Outcome Measures), 6 of which are high-

priority

• Total of 257 quality measures for 2019

MIPS Year 3 (2019) Final

Quality Performance Category

Bonus Points

Year 2 (2018) Final Year 3 (2019) Final

• 2 points for outcome or

patient experience

• 1 point for other high-

priority measures

• 1 point for each

measure submitted

using electronic end-to-

end reporting

• Cap bonus points at

10% of category

denominator

• Same requirements as

Year 2, with the following

changes:

• Add small practice

bonus of 6 points for

MIPS eligible clinicians in

small practices who

submit data on at least 1

quality measure

• Updated the definition of

high-

priority to include the

opioid-related measures

Quick Tip: A small practice is defined as 15 or fewer eligible clinicians

Basics:

• 45% of Final Score in 2019

• You select 6 individual measures

̶ 1 must be an outcome measure

̶ High-priority measure

• If less than 6 measures apply, then

report on each applicable measure

• You may also select a specialty-

specific set of measures

MIPS Year 3 (2019) Final

Quality Performance Category

Data Completeness

Year 2 (2018) Final Year 3 (2019) Final

• 60% for submission

mechanisms except for

Web Interface and

CAHPS

• Measures that do not

meet the data

completeness criteria

earn 1 point

• Small practices

continue to receive 3

points

Same requirements as

Year 2

Basics:

• 45% of Final Score in 2019

• You select 6 individual measures

̶ 1 must be an outcome measure

̶ High-priority measure

• If less than 6 measures apply, then

report on each applicable measure

• You may also select a specialty-

specific set of measures

MIPS Year 3 (2019) Final

Quality Performance Category

Basics:

• 45% of Final Score in 2019

• You select 6 individual measures

̶ 1 must be an outcome measure

̶ High-priority measure

• If less than 6 measures apply, then

report on each applicable measure

• You may also select a specialty-

specific set of measures

Special Scoring Considerations

Measures Impacted by Clinical Guideline Changes

• CMS will identify measures for which following the

guidelines in the existing measure specification could

result in patient harm or otherwise provide misleading

results as to good quality care

• Clinicians who are following the revised clinical

guidelines will still need to submit the impacted

measure

• The total available measure achievement points in the

denominator will be reduced by 10 points for each

impacted measure and the numerator of the impacted

measure will result in zero points

Groups Registered to Report the CAHPS for MIPS

Survey

• If the sample size was not sufficient and if the group

doesn’t select another measure, the total available

measure achievement points will be reduced by 10

and the measures will receive zero points

MIPS Year 3 (2019) Final

Quality Performance Category

Basics:

• 45% of Final Score in 2019

• You select 6 individual measures

̶ 1 must be an outcome measure

̶ High-priority measure

• If less than 6 measures apply, then

report on each applicable measure

• You may also select a specialty-

specific set of measures

Improvement Scoring

Year 2 (2018) Final Year 3 (2019) Final

• Eligible clinicians must

fully participate (i.e.

submit all required

measures and have

met data completeness

criteria) for the

performance period

• If the eligible clinician

has a previous year

Quality performance

category score less

than or equal to 30%,

we would compare

2018 performance to

an assumed 2017

Quality performance

category score of 30%

Same requirements as

Year 2

MIPS Year 3 (2019) Final

Quality Performance Category

Basics:

• 45% of Final Score in 2019

• You select 6 individual measures

̶ 1 must be an outcome measure

̶ High-priority measure

• If less than 6 measures apply, then

report on each applicable measure

• You may also select a specialty-

specific set of measures

Topped-out Measures

Year 2 (2018) Final Year 3 (2019) Final

• A topped out measure is

when performance is so

high and unwavering that

meaningful distinctions

and improvement in

performance can no

longer be made

• 4-year lifecycle to identify

and remove topped out

measures

•

Scoring cap of 7 points for

topped out measures

Same requirements as Year

2, with the following changes:

• Extremely Topped-Out

Measures:

̶ A measure attains

extremely topped-out

status when the

average mean

performance is within

the 98

to 100

percentile range

• CMS may propose

removing the measure

in the next rulemaking

cycle

• QCDR measures are

excluded from the topped

out measure lifecycle and

special scoring policies

MIPS Year 3 (2019) Final

Cost Performance Category

Basics:

• 15% of Final Score in 2019

• Measures:

̶ Medicare Spending Per

Beneficiary (MSPB)

̶ Total Per Capita Cost

̶ Adding 8 episode-based

measures

• No reporting requirement; data

pulled from administrative claims

• No improvement scoring in Year 3

Measure Case Minimums

Year 2 (2018) Final Year 3 (2019) Final

• Case minimum

of 20 for

Total per Capita Cost

measure and 35 for

MSPB

Same requirements as

Year 2, with the following

additions:

• Case minimum of 10 for

procedural episodes

• Case minimum of 20 for

acute inpatient medical

condition episodes

MIPS Year 3 (2019) Final

Cost Performance Category

Basics:

• 15% of Final Score in 2019

• Measures:

̶ Medicare Spending Per

Beneficiary (MSPB)

̶ Total Per Capita Cost

̶ Adding 8 episode-based

measures

• No reporting requirement; data

pulled from administrative claims

• No improvement scoring in Year 3

Measure Attribution

Year 2 (2018) Final Year 3 (2019) Final

• Plurality of primary care

services rendered by the

clinician to determine

attribution for the Total

per Capita Cost measure

• Plurality of Part B

services billed during the

index admission to

determination attribution

for the MSPB measure

• Added two

CPT codes to

the list of primary care

services used to

determine attribution

under the Total per

Capita Cost measure

Same requirements as Year

2, with the following additions:

• For procedural episodes:

CMS will attribute episodes to

the clinician that performs the

procedure

• For acute inpatient medical

condition episodes: CMS will

attribute episodes to each

clinician who bills inpatient

evaluation and management

(E&M) claim lines during a

trigger inpatient

hospitalization under a TIN

that renders at least 30

percent of the inpatient E&M

claim lines in that

hospitalization

MIPS Year 3 (2019) Final

Cost Performance Category

Episode-Based Measures Finalized for the 2019 MIPS Performance Period

• Beginning with the 2019 MIPS performance period, eight episode-based measures will also

be used to evaluate cost. The eight episode-based cost measures are highlighted below.

Measure Topic Measure Type

Elective Outpatient Percutaneous Coronary

Intervention (PCI)

Procedural

Knee Arthroplasty Procedural

Revascularization for Lower Extremity Chronic

Critical Limb Ischemia

Procedural

Routine Cataract Removal with Intraocular

Lens (IOL) Implantation

Procedural

Screening/Surveillance Colonoscopy Procedural

Intracranial Hemorrhage or Cerebral Infarction Acute inpatient medical condition

Simple Pneumonia with Hospitalization Acute inpatient medical condition

ST-Elevation Myocardial Infarction (STEMI)

with Percutaneous Coronary Intervention (PCI)

Acute inpatient medical condition

MIPS Year 3 (2019) Final

Facility-based Quality and Cost Performance Measures

What is it?

• Facility-based scoring is an option for clinicians that meet certain criteria beginning

with the 2019 performance period

– CMS finalized this policy for the 2019 performance period in the 2018 Final

Rule

– Facility-based scoring allows for certain clinicians to have their Quality and

Cost performance category scores based on the performance of the hospitals

at which they work

MIPS Year 3 (2019) Final

Facility-based Quality and Cost Performance Measures

Applicability: Individual

• MIPS eligible clinician furnishes 75% or more of their covered professional services in

inpatient hospital (Place of Service code 21), on-campus outpatient hospital (POS

22), or an emergency room (POS 23), based on claims for a period prior to the

performance period

• Clinician would be required to have at least a single service billed with POS code

used for inpatient hospital or emergency room

Applicability: Group

• Facility-based group would be one in which 75% or more of eligible clinicians billing

under the group’s TIN are eligible for facility-based measurement as individuals

MIPS Year 3 (2019) Final

Facility-based Quality and Cost Performance Measures

Attribution

• Facility-based clinician would be attributed to hospital where they provide services to most patients

• Facility-based group would be attributed to hospital where most facility-based clinicians are

attributed

• If unable to identify facility with the Hospital Value-based Purchasing (VBP) score to attribute

clinician’s performance, that clinician would not be eligible for facility-based measurement and

would have to participate in MIPS via other methods

Election

• Automatically apply facility-based measurement to MIPS eligible clinicians and groups who are

eligible for facility-based measurement and who would benefit by having a higher combined Quality

and Cost score

• No submission requirements for individual clinicians in facility-based measurement, but a group

would need to submit data for the Improvement Activities or Promoting Interoperability performance

categories in order to be measured as a facility-based group

MIPS Year 3 (2019) Final

Facility-based Quality and Cost Performance Measures

Measurement

• For facility-based measurement, the measure set for the fiscal year Hospital VBP Program that

begins during the applicable MIPS performance period would be used for facility-based clinicians

• Example: For the 2019 MIPS performance period (Year 3), the measures used would be those for

the 2020 Hospital VBP Program along with the associated benchmarks and performance periods

Benchmarks

• Benchmarks for facility-based measurement are those that are adopted under the hospital VBP

Program of the facility for the year specified

MIPS Year 3 (2019) Final

Facility-based Quality and Cost Performance Measures

Assigning MIPS Category Scores

• The Quality and Cost performance category scores (which are separate scores) for facility-based

clinicians are based on how well the clinician’s hospital performs in comparison to other hospitals in

the Hospital VBP Program

Scoring – Special Rules

• Some hospitals do not receive a Total Performance Score in a given year in the Hospital VBP

Program, whether due to insufficient quality measure data, failure to meet requirements under the

Hospital In-patient Quality Reporting (IQR) Program, or other reasons

• In these cases, we would be unable to calculate a facility-based score based on the hospital’s

performance, and facility-based clinicians would be required to participate in MIPS via another

method

MIPS Year 3 (2019) Final

Improvement Activities Performance Category

Basics:

• 15% of Final Score in 2019

• Select Improvement Activities and

attest “yes” to completing

• Activity weights remain the same:

• Medium = 10 points

• High = 20 points

• Small practices, non-patient

facing clinicians, and/or

clinicians located in rural or

HPSAs continue to receive

double-weight and report on no

more than 2 activities to receive

the highest score

Activity Inventory

CEHRT Bonus

• Added 6 new Improvement Activities

• Modified 5 existing Improvement Activities

• Removing 1 existing Improvement Activity

• Total of 118 Improvement Activities for 2019

• Removed the bonus to align with the new Promoting

Interoperability scoring requirements, which no longer

consists of a bonus score component

MIPS Year 3 (2019) Final

Promoting Interoperability Performance Category

Basics:

• 25% of Final Score in 2019

• Must use 2015 Edition Certified

EHR Technology (CEHRT) in

2019

• New performance-based scoring

• 100 total category points

Reporting Requirements

Year 2 (2018) Final Year 3 (2019) Final

• Comprised of a base,

performance, and

bonus score

• Must fulfill the base

score requirements to

earn a Promoting

Interoperability score

• Eliminated the base,

performance, and bonus

scores

• New performance-

based scoring at the

individual measure level

• Must report the required

measures under each

Objective, or claim

exclusions if applicable

MIPS Year 3 (2019) Final

Promoting Interoperability Performance Category

Basics:

• 25% of Final Score in 2019

• Must use 2015 Edition Certified

EHR Technology (CEHRT) in

2019

• New performance-based scoring

• 100 total category points

Objectives and Measures

Year 2 (2018) Final Year 3 (2019) Final

•

Two measure set options

for reporting based on

the MIPS eligible

clinician’s edition of

CEHRT (either 2014 or

2015)

• One set of Objectives and

Measures based on 2015

Edition CEHRT

• Four Objectives: e-

Prescribing, Health

Information Exchange,

Provider to Patient

Exchange, and Public

Health and Clinical Data

Exchange

• Added two new measures

to the e-Prescribing

Objective: Query of

Prescription Drug

Monitoring Program

(PDMP) and Verify Opioid

Treatment Agreement

MIPS Year 3 (2019) Final

Promoting Interoperability Performance Category – Point Value

Objectives Measures Maximum Points

e-Prescribing

• e-Prescribing • 10 points

• Query of Prescription Drug Monitoring Program

(PDMP) (new)

• 5 bonus points

• Verify Opioid Treatment Agreement (new) • 5 bonus points

Health

Information

Exchange

• Support Electronic Referral Loops by Sending Health

Information (formerly Send a Summary of Care)

• 20 points

• Support Electronic Referral Loops by Receiving and

Incorporating Health Information (new)

• 20 points

Provider to

Patient Exchange

• Provide Patients Electronic Access to their Health

Information (formerly Provide Patient Access)

• 40 points

Public Health and

Clinical Data

Exchange

• Immunization Registry Reporting

• Electronic Case Reporting

• Public Health Registry Reporting

• Clinical Data Registry Reporting

• Syndromic Surveillance Reporting

• 10 points

MIPS Year 3 (2019) Final

Promoting Interoperability Performance Category

Basics:

• 25% of Final Score in 2019

• Must use 2015 Edition Certified

EHR Technology (CEHRT) in

2019

• New performance-based scoring

• 100 total category points

Scoring

To earn a score for the Promoting Interoperability

Performance Category, a MIPS eligible clinician must:

1. Use 2015 Edition CEHRT for the performance

period (90 consecutive days or greater)

2. Submit a “yes” to the Prevention of Information

Blocking Attestation

3. Submit a “yes” to the ONC Direct Review Attestation

4. Submit a “yes” for the security risk analysis measure

5. Report the required measures under each

Objective, or claim exclusions, if applicable

MIPS Year 3 (2019) Final

Promoting Interoperability Performance Category

Basics:

• 25% of Final Score in 2019

• Must use 2015 Edition Certified

EHR Technology (CEHRT) in

2019

• New performance-based scoring

• 100 total category points

Scoring

Year 2 (2018) Final Year 3 (2019) Final

• Fulfill the base score

(worth 50%) by

submitting at least a 1 in

the numerator of certain

measures AND submit

“yes” for the Security

Risk Analysis measure

• Performance score

(worth 90%) is

determined by a

performance rate for

each submitted measure

•

Bonus score (worth 25%)

is available

•

Maximum score is 165%,

but is capped at 100%

• Performance-based scoring

at the individual measure

level

•

Each measure will be scored

on performance for that

measure based on the

submission of a numerator

and denominator, or a “yes

or no”

• Must submit a

numerator of at least

one or a “yes” to fulfill

the required measures

• The scores for each of the

individual measures will be

added together to calculate

a final score

• If exclusions are claimed,

the points will be allocated to

other measures

Exclusions

• e-Prescribing measure, if exclusion is claimed, 10 points will be distributed:

– 5 points to Support Electronic Referral Loops by Sending Health Information

– 5 points to Support Electronic Referral Loops by Receiving and Incorporating Health

Information

Support Electronic Referral Loops by Receiving and Incorporating Health Information, if

exclusion is claimed:

– Redistribute 20 points to the Support Electronic Referral Loops by Sending Health

Information measure

• Support Electronic Referral Loops by Sending Health Information measure - TBD

• Public Health exclusions, if 2 exclusions are claimed:

– Redistribute 10 points to the Provide Patients Electronic Access to Their Health Information

measure, if report yes for 2 measures or report 1 and claim 1 exclusion.

Promoting Interoperability

Scoring

MIPS Year 3 (2019) Final

Promoting Interoperability Performance Category – Scoring Example

Objectives Measures

Maximum

Points

Numerator/

Denominator

Performance

Rate

Score

e-Prescribing • e-Prescribing • 10 points • 200/250 80% 10 x 0.8 = 8 points

Health

Information

Exchange

• Support Electronic

Referral Loops by

Sending Health

Information

• 20 points • 135/185 73% 20 x 0.73 = 15 points

• Support Electronic

Referral Loops by

Receiving and

Incorporating Health

Information

• 20 points • 145/175 83% 20 x 0.83 = 17 points

Provider to

Patient

Exchange

• Provide Patients

Electronic Access to

their Health

Information

• 40 points • 350/500 70% 40 x 0.70 = 28 points

Public Health

and Clinical

Data

Exchange

• Immunization

Registry Reporting

• Public Health

Registry Reporting

• 10 points • Yes

• Yes

N/A 10 points

Total 78 Points

MIPS Year 3 (2019) Final

Promoting Interoperability Performance Category – Scoring Example

Total Score

(from previous slide)

78 points

Calculate the contribution to

MIPS Final Score

78 x .25 (the category value) = 19.5

performance

category points

Final Performance Category

Score

19.5 points

out of the 25

performance category points

MIPS Year 3 (2019) Final

Promoting Interoperability Performance Category

Basics:

• 25% of Final Score in 2019

• Must use 2015 Edition Certified

EHR Technology (CEHRT) in

2019

• New performance-based scoring

• 100 total category points

Reweighting

Year 2 (2018) Final Year 3 (2019) Final

• Automatic reweighting

for the following MIPS

eligible clinicians: Non-

Patient Facing,

Hospital-based,

Ambulatory Surgical

Center-based, PAs,

NPs, Clinical Nurse

Specialists, and

CRNAs

• Application based

reweighting also

available for certain

circumstances

• Example:

clinicians who

are in small

practices

Same requirements as Year

2, with the following additions:

• Extended the automatic

reweighting for:

• Physical Therapists

• Occupational

Therapists

• Clinical

Psychologists

• Speech-Language

Pathologists

• Audiologists

• Registered

Dieticians or

Nutrition

Professionals

Final Rule for Year 3 (2019) – MIPS

Additional Bonuses, Performance Threshold,

and Payment Adjustments

MIPS Year 3 (2019) Final

Complex Patient Bonus

Same requirements as Year 2:

• Up to 5 bonus points available for treating complex patients based on medical

complexity

• As measured by Hierarchical Condition Category (HCC) risk score and a score

based on the percentage of dual eligible beneficiaries

• MIPS eligible clinicians or groups must submit data on at least 1 performance

category in an applicable performance period to earn the bonus

MIPS Year 3 (2019) Final

Performance Threshold and Payment Adjustments

• 15 point performance threshold

• Additional payment adjustment for

exceptional performance bonus set at 70

points

• Payment adjustment could be up to +5% or

as low as -5%*

• Payment adjustment (and additional

payment adjustment for exceptional

performance) is based on comparing final

score to performance threshold and

additional performance threshold for

exceptional performance

Year 2 (2018) Final

• 30 point performance threshold

• Additional payment adjustment for

exceptional performance bonus set

at 75 points

• Payment adjustment could be up to

+7% or as low as -7%*

• Payment adjustment (and additional

payment adjustment for exceptional

performance) is based on comparing

final score to performance threshold

and additional performance threshold

for exceptional performance

Year 3 (2019) Final

*To ensure budget neutrality, positive MIPS payment adjustment factors are likely to be increased or decreased by an amount called a

“scaling factor.” The amount of the scaling factor depends on the distribution of final scores across all MIPS eligible clinicians.

MIPS Year 3 (2019) Final

Performance Threshold and Payment Adjustments

Year 2 (2018) Final Year 3 (2019) Final

Final

Score

2018

Payment Adjustment 2020

>70

points

 Positive adjustment greater than 0%

 Eligible for additional payment

adjustment for exceptional

performance - minimum of additional

0.5%

15.01-

69.99

points

 Positive adjustment greater than 0%

 Not eligible for additional payment

for exceptional performance

points

 Neutral payment adjustment

3.76-

14.99

 Negative payment adjustment

greater than -5% and less than 0%

0-3.75

points

 Negative payment adjustment of -5%

Final

Score

2019

Payment Adjustment 2021

>75

points

 Positive adjustment greater than 0%

 Eligible for additional payment

adjustment for exceptional

performance - minimum of additional

0.5%

30.01-

74.99

points

 Positive adjustment greater than 0%

 Not eligible for additional payment for

exceptional performance

points

 Neutral payment adjustment

7.51-

29.99

 Negative payment adjustment

greater than -7% and less than 0%

0-7.5

points

 Negative payment adjustment of -7%

Quality Payment Program

Help & Support

Technical Assistance

Available Resources

CMS has free resources and organizations on the ground to provide help to clinicians

who are participating in the Quality Payment Program:

Learn more about technical assistance: https://qpp.cms.gov/about/help-and-support#technical-assistance

Session Title

Session #

Room #

Date

Start Time

End Time

Meaningful

Measures

#113

W307A

Wed., 2/13

10:00 a.m.

11:00 a.m.

Balancing

Value &

Burden: CMS

Electronic

Quality

Reporting

#199

W307A

Thurs., 2/14

8:30 a.m.

9:30 a.m.

CMS

Interoperability

Rule

#233

W307A

Thurs., 2/14

11:30 a.m.

12:30 p.m.

Additional CMS Education Sessions

Molly MacHarris, MIPS Program Lead, CMS

Elizabeth S. Holland, Senior Technical Advisor, CMS

Questions